Chapter 49

49.45(6m)(ar)1. 1. For direct care costs:

49.45(6m)(ar)1.a. a. The department shall establish standards for payment of allowable direct care costs under par. (am) 1. bm., for facilities that do not primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state and separate standards for payment of allowable direct care costs, for facilities that primarily serve the developmentally disabled, that take into account direct care costs for a sample of all of those facilities in this state. The standards shall be adjusted by the department for regional labor cost variations. The department shall treat as a single labor region the counties of Dane, Dodge, Iowa, Columbia, Richland, Sauk, and Rock and shall adjust payment so that the direct care cost targets of facilities in Dane, Iowa, Columbia, and Sauk counties are not reduced as a result of including facilities in Dodge, Richland, and Rock Counties in this labor region. For facilities in Douglas, Dunn, Pierce, and St. Croix counties, the department shall perform the adjustment by use of the wage index that is used by the federal department of health and human services for hospital reimbursement under 42 USC 1395 to 1395ggg.

49.45(6m)(ar)1.b. b. The department shall establish the direct care component of the facility rate for each facility by comparing actual allowable direct care cost information of that facility adjusted for inflation to the standards established under subd. 1. a.

49.45(6m)(ar)1.c. c. If a facility has an approved program for provision of service to residents who have an intellectual disability, residents dependent upon ventilators, or residents requiring supplemental skilled care due to complex medical conditions, a supplement to the direct care component of the facility rate under subd. 1. b. may be made to that facility according to a method developed by the department.

49.45(6m)(ar)1.cm. cm. Funding distributed to facilities for the provision of active treatment to residents with a diagnosis of developmental disability shall be distributed in accordance with a method developed by the department which is consistent with a prudent buyer approach to payment for services.

49.45(6m)(ar)2. 2. For support service costs, the department shall establish one or more standards for the payment of support service costs that take into account support service costs for a sample of all facilities within the state.

49.45(6m)(ar)4. 4. For net property taxes or municipal services, payment shall be made for the amount of the previous calendar year’s tax or the amount of municipal service costs for a period specified by the department, subject to a maximum limit as determined by the department.

49.45(6m)(ar)6. 6. Capital payment shall be based on a replacement value for a facility. The replacement value shall be determined by a commercial estimator contracted for by the department and paid for by the facility. The replacement value shall be subject to limitations determined by the department.

49.45(6m)(av) (av) The department shall calculate a payment rate for a facility by applying the criteria set forth under pars. (ag) 1. to 5. and 7., (am) 1. bm., 4., 5m. and 6., and (ar) 1., 4., and 6. to information from cost reports submitted by the facility, as affected by any adjustment for ancillary services and materials under par. (b).

49.45(6m)(b) (b) The charges for ancillary materials and services that would be incurred by a prudent buyer may be included as an adjustment to the rate determined by par. (av) when so determined by the department. The department may not authorize any adjustments to the rate established under par. (av) to pay for a cost overrun that the department fails to approve under s. 150.11 (3). Ancillary materials and services for which payment may be made include, if provided, oxygen, medical transportation and laboratory and X-ray services. Payment for these services and materials shall not exceed medical assistance limitations for reimbursement of the services and materials. For services in a facility for which the department may make payment to a service provider other than a facility, the department may make payment to the facility but not in excess of the estimated amount of payment available if a separate service provider provided the service. The department may promulgate rules setting forth conditions of and limitations to this paragraph.

49.45(6m)(bg) (bg) The department shall determine payment levels for the provision of skilled, intermediate, limited, personal or residential care or care for individuals with an intellectual disability in the state centers for the developmentally disabled and in a Wisconsin veterans home operated by the department of veterans affairs under s. 45.50 separately from the payment principles, applicable costs and methods established under this subsection.

49.45(6m)(bm) (bm) Except as provided in par. (bo), the department may establish payment methods for a facility for which any of the following applies:

49.45(6m)(bm)1. 1. The facility is newly constructed.

49.45(6m)(bm)2. 2. The total of licensed beds for the facility has significantly increased or decreased prior to calculation of its rate under the payment system.

49.45(6m)(bm)3. 3. The facility has undergone a change in certification or licensure level.

49.45(6m)(bm)5. 5. The facility has received approval or disapproval for provision of service to residents requiring supplemental skilled care due to complex medical conditions.

49.45(6m)(bm)6. 6. The facility has received approval or been disapproved for provision of service to residents who have any of the following:

49.45(6m)(bm)6.a. a. Brain injury, as defined in s. 51.01 (2g).

49.45(6m)(bm)6.b. b. A diagnosis of acquired immunodeficiency syndrome.

49.45(6m)(bm)6.c. c. An HIV infection, as defined in s. 252.01 (2), and illness or injury associated with the development of acquired immunodeficiency syndrome.

49.45(6m)(bo) (bo) The department may establish payment methods for capital payment for a newly constructed facility that first provided services after June 30, 1984.

49.45(6m)(bp) (bp) Notwithstanding pars. (am) 6. and (ar) 6., the department may establish payment methods based on actual costs for capital payment for a facility to which, after December 31, 1982, any of the following applies:

49.45(6m)(bp)1. 1. The facility was constructed.

49.45(6m)(bp)2. 2. The facility was purchased.

49.45(6m)(bp)3. 3. The facility incurred annual remodeling costs of more than $600,000.

49.45(6m)(bp)4. 4. The facility incurred remodeling costs necessary to meet physical plant requirements under 42 USC 1396a (a) (13) (A).

49.45(6m)(br) (br) If the federal department of health and human services disallows use of the allocation of matching federal medical assistance funds under applicable federal acts or programs for the reduction of operation deficits under sub. (6u), all of the following apply:

49.45(6m)(br)1. 1. Notwithstanding s. 20.435 (7) (b) or 20.437 (1) (cj) or (q) or (2) (dz), the department shall reduce allocations of funds to counties in the amount of the disallowance from the appropriation account under s. 20.435 (7) (b), or the department shall direct the department of children and families to reduce allocations of funds to counties or Wisconsin Works agencies in the amount of the disallowance from the appropriation account under s. 20.437 (1) (cj) or (2) (dz), in accordance with s. 16.544 to the extent applicable.

49.45(6m)(br)2. 2. If a city, village or town owns and operates a facility that has received funds to reduce an operating deficit, the city, village or town shall reimburse the county in which the city, village or town is located in the amount of funds so received.

49.45(6m)(c) (c) As a condition of payment under this section a facility shall:

49.45(6m)(c)1. 1. Meet the staffing standard requirements for direct care costs including the supplement, if any, made under par. (ar) 1. c. and maintain such records as prescribed by the department to document that such level of care was actually provided.

49.45(6m)(c)2. 2. Provide at the time of a patient’s admission to a home, for the development and implementation of a rehabilitation plan including the development of an alternate care plan for the patient.

49.45(6m)(c)3. 3. Provide, upon request, cost information relating to the overall financial operation of the facility, including, but not limited to wages and hours worked, costs of food, housekeeping, maintenance and administration.

49.45(6m)(c)4. 4. Agree to admit patients 7 days of the week.

49.45(6m)(c)5. 5. Admit only patients if required under s. 50.035 (4n) or 50.04 (2h), who have been referred to a resource center.

49.45(6m)(c)6. 6. Provide, upon request, such information as the department considers necessary to determine allowable interest expenses under par. (am) 5m.

49.45(6m)(d) (d) The department shall:

49.45(6m)(d)2. 2. Terminate payment to a facility for a patient, unless a utilization review team established pursuant to federal regulations upon review of the patient’s needs and the implementation of a rehabilitation plan for that patient determines that the patient’s need for care and services can only be provided in a facility and determines the appropriate level of care.

49.45(6m)(d)3. 3. Establish, maintain, and periodically update a patient needs evaluation system to be used in determining the need and level of care at a facility, which shall include the social and rehabilitative needs of the patient, provide levels of care to correspond to the actual staff time required to provide such care, and define the contents of the services to be provided.

49.45(6m)(d)4. 4. Periodically audit all nursing homes and intermediate care facilities receiving funds under this paragraph, and recover payments made where the home is not meeting the conditions under which the payment was made as specified in par. (c) 1. and 2. Erroneous information provided under par. (c) 3. shall constitute grounds for recovery.

49.45(6m)(d)5. 5. Beginning October 1, 1989, deny payment to a facility for a patient who is admitted to the facility after the department has provided newspaper notice and notice under s. 50.03 (2m) (b) that the facility violates 42 USC 1396 to 1396s and before the date, if any, that the department determines that the facility is in substantial compliance with 42 USC 1396 to 1396s.

49.45(6m)(g) (g) Payment under this section to a facility may not include the cost of care reimbursable for persons eligible for medicare benefits under 42 USC 1395 to 1395zz. Medical assistance recipients are not liable for these costs. The department may require that a facility recover these costs from the appropriate agencies. The department may, by rule, require medicare certification under 42 USC 1395 to 1395zz, in whole or in part, of skilled nursing facilities. Any intermediate care facility or skilled nursing facility is subject to a fine of not less than $10 nor more than $100 for each day it refuses to recover costs or refuses to obtain the required certification.

49.45(6m)(h) (h) The department may require by rule that all claims for payment of services provided facility residents under this subchapter be submitted or countersigned by the respective facility administrator. The department may specify those categories of services for which payment will be made only if the services are rendered or authorized in writing by a primary health care provider designated by the recipient for the particular category of services.

49.45(6m)(i) (i)

49.45(6m)(i)1. 1. On or after October 1, 1981, medical assistance payment for inpatient nursing care may only be provided for persons receiving skilled, intermediate, or limited levels of nursing care as these levels are defined under s. DHS 132.13, Wis. Adm. Code.

49.45(6m)(i)2. 2. Payment for personal or residential care is available for a person in a facility certified under 42 USC 1396 to 1396p only if the person entered a facility before the date specified in subd. 1. and has continuously resided in a facility since the date specified in subd. 1. If the person has a primary diagnosis of developmental disabilities or serious and persistent mental illness, payment for personal or residential care is available only if the person entered a facility on or before November 1, 1983.

49.45(6m)(j) (j) The department may develop a separate rate of payment, under this subsection, for persons requiring intense skilled nursing care, as defined by the department.

49.45(6m)(k) (k) Notwithstanding pars. (ag) to (b), (bp) and (br), the department may participate in a demonstration project on case mix nursing home reimbursement authorized under 42 USC 1315 (a) and may modify the payment system under this section, on an experimental basis, as necessary for participation in the demonstration project.

49.45(6m)(L) (L) For purposes of s. 46.277 (5) (e), the department shall, by July 1 annually, determine the statewide medical assistance daily cost of nursing home care and submit the determination to the department of administration for review. The department of administration shall approve the determination before payment may be made under s. 46.277 (5) (e).

49.45(6m)(m) (m) To hold a bed in a facility, the department may pay the full payment rate under this subsection for up to 30 days for services provided to a person during the pendency of an undue hardship determination, as provided in s. 49.453 (8) (b) 3.

49.45(6tw) (6tw) Payments to city health departments. From the appropriation account under s. 20.435 (7) (b), if the department selects the payment procedure under sub. (52) (a), the department may make payments to local health departments, as defined under s. 250.01 (4) (a) 3. Payment under this subsection to such a local health department may not exceed on an annualized basis payment made by the department to the local health department under s. 49.45 (6t), 2003 stats., for services provided by the local health department in 2002.

49.45(6u) (6u) Supplemental payments to certain facilities and care management organizations.

49.45(6u)(ag) (ag) In this subsection:

49.45(6u)(ag)1. 1. “Care management organization” means a care management organization, as defined in s. 46.2805 (1), that contracts under s. 46.284 (4) (d) for provision of services with a facility that is established under s. 49.70 (2) or that is owned and operated by a city, village, or town.

49.45(6u)(ag)2. 2. “Facility” has the meaning given in sub. (6m) (a) 3.

49.45(6u)(am) (am) Notwithstanding sub. (6m), from the appropriations under s. 20.435 (4) (o), and (w), for reduction of operating deficits, as defined under the methodology used by the department in December 2000, incurred by a facility that is established under s. 49.70 (1) or that is owned and operated by a city, village, or town, and as payment to care management organizations, the department may not distribute to these facilities and to care management organizations more than $39,100,000 in each fiscal year, as determined by the department. The total amount that a county certifies under this subsection may not exceed 100 percent of otherwise-unreimbursed care. In distributing funds under this subsection, the department shall perform all of the following:

49.45(6u)(am)1. 1. Estimate the availability of federal medical assistance funds that may be matched to county funds or funds of a city, village or town for the reduction of operating deficits incurred by the facility.

49.45(6u)(am)2. 2. Based on the amount estimated available under subd. 1., develop a method to distribute this allocation to the individual facilities that have incurred operating deficits that shall include:

49.45(6u)(am)2.a. a. Development of criteria for determining operating deficits.

49.45(6u)(am)2.b. b. Agreement by the county in which is located the facility established under s. 49.70 (1) and agreement by the city, village, or town that owns and operates the facility that the applicable county, city, village, or town shall provide funds to match federal medical assistance matching funds under this paragraph.

49.45(6u)(am)2.bm. bm. Identification by the county in which is located the facility established under s. 49.70 (1) of all county funds expended in each calendar year to operate the facility, and certification by the county to the department of this amount.

49.45(6u)(am)2.c. c. Consideration of the size of a facility’s operating deficit.

49.45(6u)(am)3. 3. Distribute the allocation under the distribution method that is developed, unless a county has failed to comply with subd. 2. bm.

49.45(6u)(am)4. 4. If the federal department of health and human services approves for state expenditure in a fiscal year amounts under s. 20.435 (4) (o) and (w) that result in a lesser allocation amount than that allocated under this paragraph, allocate not more than the lesser amount so approved by the federal department of health and human services.

49.45(6u)(am)5. 5. If the federal department of health and human services approves for state expenditure in a fiscal year amounts under s. 20.435 (4) (o) and (w) that result in a lesser allocation amount than that allocated under this paragraph, submit a revision of the method developed under subd. 2. for approval by the joint committee on finance in that state fiscal year.

49.45(6u)(am)6. 6. If the federal department of health and human services disallows use of the allocation of matching federal medical assistance funds distributed under subd. 3., apply the requirements under sub. (6m) (br).

49.45(6u)(am)7. 7. If a facility that is otherwise eligible for an allocation of funds under this section is found by the federal health care financing administration or the department to be an institution for mental diseases, as defined under 42 CFR 435.1009, cease distributing to that facility funds under this section after the date on which the finding is made.

49.45(6u)(b) (b) Notwithstanding the limitation on the amount of disbursements under par. (am) (intro.), from the appropriation under s. 20.435 (4) (wm), the department shall, using the criteria specified in par. (am) 1. to 7., disburse any federal medical assistance funds that are received by the state as federal financial participation for operating deficits incurred by a facility that is operated by a county, city, village, or town and that are in excess of the amount of federal financial participation anticipated and budgeted as revenue in the biennial budget act for the fiscal year in which the funds are received.

49.45(6w) (6w) Hospital operating deficit reduction. From the appropriation under s. 20.435 (4) (o), for reduction of operating deficits, as defined under criteria developed by the department, incurred by a hospital, as defined under s. 50.33 (2) (a) and (b), that is operated by the state, established under s. 49.71 or owned and operated by a city or village, the department shall allocate up to $3,300,000 in each fiscal year to these hospitals, as determined by the department, and shall perform all of the following:

49.45(6w)(a) (a) For the reduction of operating deficits incurred by the hospital, estimate the availability of federal medicaid funds that may be matched to any of the following:

49.45(6w)(a)1. 1. State general purpose revenues, for a hospital operated by the state.

49.45(6w)(a)2. 2. County funds, for a hospital established under s. 49.71.

49.45(6w)(a)3. 3. Funds of a city or village, for a hospital owned and operated by a city or village.

49.45(6w)(b) (b) Based on the amount estimated available under par. (a), develop a method to distribute this allocation to the individual hospitals that have incurred operating deficits that shall include:

49.45(6w)(b)1. 1. Development of criteria for determining operating deficits.

49.45(6w)(b)2. 2. With respect to funds to match federal medicaid matching funds under this section, any of the following, as applicable:

49.45(6w)(b)2.a. a. Provision by the state of matching funds from general purpose revenues for a hospital operated by the state.

49.45(6w)(b)2.b. b. Agreement to provide matching funds by the county in which is located a hospital established under s. 49.71.

49.45(6w)(b)2.c. c. Agreement to provide matching funds by the city or village that owns and operates a hospital.

49.45(6w)(b)3. 3. Consideration of the size of a hospital’s operating deficit.

49.45(6w)(c) (c) Except as provided in par. (d), distribute the allocation under the distribution method that is developed.

49.45(6w)(d) (d) If the federal department of health and human services approves for state expenditure in a fiscal year amounts under s. 20.435 (4) (o) that result in a lesser allocation amount than that allocated under this subsection or disallows use of the allocation of federal medicaid funds under par. (c), reduce allocations under this subsection and distribute on a prorated basis, as determined by the department.

49.45(6x) (6x) Funding for essential access city hospital.

49.45(6x)(a) (a) Notwithstanding sub. (3) (e), from the appropriation accounts under s. 20.435 (4) (b), (gm), (o), and (w), the department shall distribute all of the following, except that the department may not allocate funds to a hospital to the extent that the allocation would exceed any limitation under 42 USC 1396b (i) (3):

49.45(6x)(a)1. 1. Not more than $2,997,700 in fiscal year 2011-12 and not more than $2,988,700 in each fiscal year after fiscal year 2011-12 to an essential access city hospital that has previously received the supplemental payment for being an essential access city hospital.

49.45(6x)(a)2. 2. Not more than $999,200 in fiscal year 2011-12 and not more than $996,200 in each fiscal year after fiscal year 2011-12 to a hospital that would qualify for an essential access city hospital supplemental payment, under the criteria described in the 2010-11 inpatient hospital state plan, except that the hospital did not meet the criteria to be an essential access city hospital during fiscal year 1995-96.

49.45(6x)(a)3. 3. If the federal department of health and human services allows the payment, $300,000 from the appropriation account under s. 20.435 (4) (b) annually to a hospital that meets all of the following criteria:

49.45(6x)(a)3.a. a. The hospital is located in a city that has a municipal border that is also a state border.

49.45(6x)(a)3.b. b. The hospital has a Medical Assistance recipient patient mix that consists of at least 25 percent of residents from a state that borders this state.